Concerns raised 6 Failure to ensure and monitor academic staff completion of student mental health training View source Insufficient effective proactive outreach to students with academic absence or performance issues View source Failure to equip academic staff to identify and appropriately engage students with neurodiversity View source Insufficient academic staff awareness and understanding of student mental health View source Gap between academic assessment and pastoral support for students View source Failure to maintain accurate and sufficiently frequent records of academic meetings and agreed actions View source See 3 more concerns
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AI-generated summary
Matthew George WICKES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew George WICKES died in hospital on 30 June 2022 after jumping from a road bridge in Southampton during an acute anxiety crisis. Concerns included university staff awareness and training on student mental health and neurodiversity, gaps between academic assessment and pastoral support, difficulties in effectively reaching struggling students, and inadequate recording of academic meetings and agreed support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University of Southampton; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure and monitor academic staff completion of student mental health training
Wider context from the report “1. Matthew was neurodiverse. It was accepted that this condition was not known by the university at the relevant time, as he was diagnosed after his commencement on his course and did not disclose his condition to the university. In the circumstances, appropriate actions and case specific assistance which might otherwise have been available to and assisted Matthew were neither implemented in response nor accessed by him. Notwithstanding Matthew’s neurodiversity – which of itself was a barrier to him being able to reach out or to seek help - I am concerned about the level of awareness, understanding and curiosity of academic staff around the mental health of students, particularly in the post-pandemic climate, where interruptions to their study and dysregulated student life have had a significant impact on their mental health.
Whilst it was explained to me that all staff are offered training on mental health management and are provided with guidance on how to support students, I am concerned that aspects of this are not made compulsory for academic staff . Where a myriad of training options are made available to staff and often required of them, with very little practical time available in which to do it, there is a risk that modules and aids with regard to mental health will not be prioritised, followed through or accessed . There is as I understand it no evident monitoring in respect of which staff have viewed or undertaken what training or indeed in respect of who has completed the modules on offer. It remains unclear as to who or how many staff have actually viewed or undertaken the online training around student mental health .
Although the process of ‘raising a concern’ by academic staff is a means by which such matters can be considered and is a process set up and encouraged through the student hubs, I am concerned that in not ensuring that academic staff are at least armed with the ability to spot or to know when to make initial enquiries of students or are clearly guided on how best to do so (particularly with regard to an understanding of the needs and skills required to liaise with students with neurodiversity), there is a risk that an over-focus on academic policies and procedures will endure and that those students who are struggling to adhere to them will be missed or overlooked.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University of Southampton; that does not assign responsibility.
PFD Monitor interpretation Insufficient effective proactive outreach to students with academic absence or performance issues
Wider context from the report “2. It was evident to the Court that very positive steps have already been undertaken in planning towards an early warning system for students in the academic year 2023/24. This will allow triggers to be identified and set for academic absence and changes in study or support behaviours (as is to be trialled in 2023/24). Such steps are to be commended and I hope will proceed at pace. However, I do have concerns that there is and remains an evident gap between the academic assessment of students and the pastoral support that they receive. I hope this will be addressed and filled – in part in the development of staff training and understanding around mental health and in what circumstances concerns should be raised (as above).
Where academic absence or performance issues are identified, I am not convinced, on the evidence heard at this inquest, that enough has yet been done to also consider how ‘reaching out’ to such students can be most effectively achieved. It was evident that much of the group-focused approaches offered by the university or the initiatives where the onus is placed on the student to come forward, may not work . Practically, how best can students – especially those with neurodiverse needs – be compassionately and empathically approached and engaged with to ensure they receive the help and validation that they probably desperately require?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University of Southampton; that does not assign responsibility.
PFD Monitor interpretation Failure to equip academic staff to identify and appropriately engage students with neurodiversity
Wider context from the report “1. Matthew was neurodiverse. It was accepted that this condition was not known by the university at the relevant time, as he was diagnosed after his commencement on his course and did not disclose his condition to the university. In the circumstances, appropriate actions and case specific assistance which might otherwise have been available to and assisted Matthew were neither implemented in response nor accessed by him. Notwithstanding Matthew’s neurodiversity – which of itself was a barrier to him being able to reach out or to seek help - I am concerned about the level of awareness, understanding and curiosity of academic staff around the mental health of students, particularly in the post-pandemic climate, where interruptions to their study and dysregulated student life have had a significant impact on their mental health.
Whilst it was explained to me that all staff are offered training on mental health management and are provided with guidance on how to support students, I am concerned that aspects of this are not made compulsory for academic staff. Where a myriad of training options are made available to staff and often required of them, with very little practical time available in which to do it, there is a risk that modules and aids with regard to mental health will not be prioritised, followed through or accessed. There is as I understand it no evident monitoring in respect of which staff have viewed or undertaken what training or indeed in respect of who has completed the modules on offer. It remains unclear as to who or how many staff have actually viewed or undertaken the online training around student mental health.
Although the process of ‘raising a concern’ by academic staff is a means by which such matters can be considered and is a process set up and encouraged through the student hubs, I am concerned that in not ensuring that academic staff are at least armed with the ability to spot or to know when to make initial enquiries of students or are clearly guided on how best to do so (particularly with regard to an understanding of the needs and skills required to liaise with students with neurodiversity ), there is a risk that an over-focus on academic policies and procedures will endure and that those students who are struggling to adhere to them will be missed or overlooked .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University of Southampton; that does not assign responsibility.
PFD Monitor interpretation Insufficient academic staff awareness and understanding of student mental health
Wider context from the report “1. Matthew was neurodiverse. It was accepted that this condition was not known by the university at the relevant time, as he was diagnosed after his commencement on his course and did not disclose his condition to the university. In the circumstances, appropriate actions and case specific assistance which might otherwise have been available to and assisted Matthew were neither implemented in response nor accessed by him. Notwithstanding Matthew’s neurodiversity – which of itself was a barrier to him being able to reach out or to seek help - I am concerned about the level of awareness, understanding and curiosity of academic staff around the mental health of students , particularly in the post-pandemic climate, where interruptions to their study and dysregulated student life have had a significant impact on their mental health.
Whilst it was explained to me that all staff are offered training on mental health management and are provided with guidance on how to support students, I am concerned that aspects of this are not made compulsory for academic staff. Where a myriad of training options are made available to staff and often required of them, with very little practical time available in which to do it, there is a risk that modules and aids with regard to mental health will not be prioritised, followed through or accessed. There is as I understand it no evident monitoring in respect of which staff have viewed or undertaken what training or indeed in respect of who has completed the modules on offer. It remains unclear as to who or how many staff have actually viewed or undertaken the online training around student mental health.
Although the process of ‘raising a concern’ by academic staff is a means by which such matters can be considered and is a process set up and encouraged through the student hubs, I am concerned that in not ensuring that academic staff are at least armed with the ability to spot or to know when to make initial enquiries of students or are clearly guided on how best to do so (particularly with regard to an understanding of the needs and skills required to liaise with students with neurodiversity), there is a risk that an over-focus on academic policies and procedures will endure and that those students who are struggling to adhere to them will be missed or overlooked.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University of Southampton; that does not assign responsibility.
PFD Monitor interpretation Gap between academic assessment and pastoral support for students
Wider context from the report “2. It was evident to the Court that very positive steps have already been undertaken in planning towards an early warning system for students in the academic year 2023/24. This will allow triggers to be identified and set for academic absence and changes in study or support behaviours (as is to be trialled in 2023/24). Such steps are to be commended and I hope will proceed at pace. However, I do have concerns that there is and remains an evident gap between the academic assessment of students and the pastoral support that they receive . I hope this will be addressed and filled – in part in the development of staff training and understanding around mental health and in what circumstances concerns should be raised (as above).
Where academic absence or performance issues are identified, I am not convinced, on the evidence heard at this inquest, that enough has yet been done to also consider how ‘reaching out’ to such students can be most effectively achieved. It was evident that much of the group-focused approaches offered by the university or the initiatives where the onus is placed on the student to come forward, may not work. Practically, how best can students – especially those with neurodiverse needs – be compassionately and empathically approached and engaged with to ensure they receive the help and validation that they probably desperately require?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University of Southampton; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and sufficiently frequent records of academic meetings and agreed actions
Wider context from the report “3. The evidence at this inquest raised concerns over the existence, frequency and accuracy of the recording and minuting of academic meetings with students , especially those between the student and Personal Academic Tutor and the Project Supervisor in the third year of study.
It was of concern to me that the University was unable to locate or provide clear minutes of supervisory catch ups, progress checks or agreed guidance or actions for Matthew. It was of further concern that the academic staff supporting and mentoring him in his third year had not provided written evidence of his progress or agreed minutes of actions etc to him.
Whilst it is recognised, particularly in a third year of study, that there must be a balance between independence and appropriate support, it would in my view be important for any student and university academic team to have a clear record of achievement or progress. This must be able to be reflected back to the student and recorded in such a way as to ensure that both student and tutor are clear and agreed as to progress that has been achieved and as to what needs to be done to move forward. The absence of such information and appropriate support, which can lead to feelings of isolation and desperation, must be avoided at all costs.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations